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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ITEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TAve-/,` St/a�;e i' -71 -7 3S <br /> OWNER/OPERATO / <br /> 0 /V7to 4� CHECK N BILLING ADDRES <br /> IP <br /> FAclurrNAME <br /> rT.'.nco Tiu <br /> SITE ADDRESS /D Road R''^6r) 9s]?6tP <br /> Street Number Direedon J Street Name L1 /—Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 1 APN$ LAND USE APPLICATION# <br /> (209 ) S - of/z <br /> PHONE#2 EXT. BOS :77 <br /> ISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> JJYOOO <br /> T. a �e CHECK If BILLING ADDRE <br /> BUSINESS NAME PHONE# FXT. <br /> nI W M n S32 3q 3/ <br /> HOME Or MAILING ADDRESS FAX# <br /> live-, (209) 5-39- 9398 <br /> QITYGer STATE C Q zip,7 9s3o <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l . DATE: <br /> 7-Z3-o Y <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENTLY1 COMpNV <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my representative. : RpA <br /> YMEN <br /> T <br /> TYPE OF SERVICE REQUESTED: CST T" Ft <br /> COMMENTS: ?ep4cp— 6k dis r-on prr-mor, -hv\k. jljL. 27Z <br /> 094 <br /> SAN JOAQUIN <br /> rw X,4 ' jert -1LFr 11(OSG.s- z&, LgtENTAIL <br /> HATH DEPARTMENT <br /> APPROVED BY: o Lt V F—r b" EMPLOYEE M (Q 3 2/ DATE: 1 27 D <br /> ASSIGNED TO: U d,j Fk.A C-- EMPLOYEE#: g3 17 DATE: —72--7t(94 <br /> Date Service Completed (if already completed): SERVICE CODE: 19 J? PIE: aZ3OQ <br /> Fee Amount: ')-7 '3. 0 0 Amount Paid *a'�9 Payment Date �( a.� QLf <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />